Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Complete Care At Southpointe during CMS and state inspections, most recent first.
A resident with a significant history of prior sacral ulcer repair, flap surgery, skin grafting, ESRD on dialysis, diabetes, morbid obesity, and limited mobility developed a facility-acquired unstageable pressure injury. The facility assessed the resident as low risk, did not document the prior pressure injury surgical history in the care record, and relied on general skin precautions and a pressure-redistribution cushion. When the wound was found, staff documentation was inconsistent about whether it was on the right buttock, left sacrum, or sacrum/buttocks, and the wound RN and APNP later described a much larger unstageable area than the initial nursing measurement.
Inaccurate PBJ staffing data was submitted for a quarter in 2025 after the facility triggered for excessively low weekend staffing affecting all 92 residents. Review of staffing schedules and posting hours did not show weekend coverage gaps, and the Scheduler stated weekend staffing was the same as weekday staffing except for a weekend supervisor not counted during the week. The NHA said the facility changed payroll systems used for PBJ reporting, but no explanation was provided for why the submitted data was not accurate.
The facility failed to follow its abuse, neglect, and exploitation policy requiring timely 4‑year background checks for staff. A CNA had an initial BID form, DOJ letter, and IBIS form completed before hire and another BID form and DOJ letter completed when the facility changed ownership, but no subsequent background check was completed within four years as required. The lapse was identified only after a surveyor requested personnel files, at which point it was determined that the CNA’s most recent documented background check was completed beyond the 4‑year timeframe, potentially affecting a portion of the 97 residents.
Improper Food Storage Temperatures and Labeling: Food storage practices were not in line with facility policy on three units. A refrigerator on one unit was observed at 52 degrees F and another at 34 degrees F, both outside the facility’s acceptable range, while a freezer on another unit had no thermometer and contained an opened, unsealed bag of mixed fruit with no label or date. Staff acknowledged the temperature issues and the unlabeled food when the surveyor pointed them out.
A resident with intact cognition and control of personal finances was found to have been exploited by a CNA who used the resident’s debit card, received cash, linked PayPal accounts, and used the resident’s cell phone. The resident said the card was given to the CNA for food ordering, but later admitted the CNA kept the card and made additional purchases. The facility’s investigation confirmed the CNA admitted to taking money and using the resident’s accounts, while staff education on abuse and misappropriation was incomplete.
A resident with severe cognitive impairment, stroke history, and bilateral hand contractures had active MD orders for both right and left palm guards, but surveyors repeatedly observed the left palm guard not in place. The left device was not listed on the care plan or CNA Kardex, and staff interviews showed confusion about the resident’s splinting needs, while the resident was consistently seen wearing only the right palm guard.
Failure to Notify Ombudsman of Hospital Transfers and Discharges: The facility did not ensure the State LTC Ombudsman was notified of multiple resident hospital transfers/discharges. A monthly discharge/transfer report used for notification did not include several residents who were sent to the hospital after changes in condition, including residents with diagnoses such as colon cancer, dementia, CKD, anemia, heart disease, diabetes, stroke, and acute renal failure. The NHA and SWD stated the report being sent did not capture all residents transferred or discharged to the hospital.
The facility inaccurately coded the MDS for three residents, affecting hospice and smoking status documentation. A resident was marked as not receiving hospice services despite being in hospice care, while two residents were incorrectly documented as non-smokers, contrary to observations and assessments. The MDS Coordinator acknowledged these errors, which did not align with the RAI 3.0 manual guidelines.
A resident with a smoking habit did not have a smoking care plan documented, despite facility policy requiring it. The resident smokes three to four times daily and does not wish to quit. Interviews with the Administrator and Unit Manager confirmed the absence of a smoking care plan, highlighting a failure to adhere to the facility's care planning process.
Failure to Prevent Facility-Acquired Pressure Injury
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and did not prevent a new pressure injury from developing for a resident admitted with a significant history of pressure injuries, including prior sacral ulcer repair, gluteal flap debridement and readvancement, and split thickness skin grafting to the left buttocks. The resident also had morbid obesity, ESRD on dialysis, diabetes, COPD, and impaired mobility. Admission documentation showed the resident was at risk for pressure injury development, had slightly limited sensory perception and mobility, and required moderate to maximum assistance with movement due to friction and shear concerns. Although the resident’s care plan included general skin integrity interventions such as repositioning, pressure relieving devices, and weekly skin checks, the facility did not document the resident’s prior pressure injury surgical history in the care record or incorporate that history into the individualized prevention plan. The resident was assessed as low risk on Braden assessments despite the documented history of prior pressure injury treatment. The resident used a pressure redistribution cushion in the wheelchair and at dialysis, but the facility did not establish resident-specific measures based on the prior flap and graft history before the skin breakdown occurred. On 2/8/26, staff identified an open area during cares and documented it inconsistently as being on the right buttock, right gluteal cleft/sacrum, and sacrum/buttocks. Initial nursing documentation included a small bleeding open area and a measurement of 1.8 cm x 0.2 cm x 0.2 cm, while the wound RN later documented a much larger unstageable wound measuring 11.0 cm x 7.0 cm with slough and epithelial tissue. The wound APNP later described the area as a large unstageable wound on the left side of the sacrum with eschar and noted the resident reported a prior flap repair. Surveyor observations and interviews showed staff continued to document the wound as right-sided while wound specialists assessed it as left sacrum/buttock, and the facility did not recognize the resident’s individualized risk factors before the facility-acquired unstageable pressure injury developed.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility did not ensure that mandatory PBJ staffing data submitted for the fourth quarter of 2025 was accurate based on payroll and other verifiable and auditable data in a uniform format according to CMS specifications. During review of the facility’s PBJ staffing data, the facility was triggered for excessively low weekend staffing, which had the potential to affect all 92 residents. Surveyor review of the facility’s assessment, staffing hours, and acuity levels of care showed the assessment documented staffing ratios needed in the facility and also triggered for low weekend staffing for the quarter in question. Surveyor review of nursing schedules and nurse staff posting hours for that period did not identify documented trends or gaps in weekend staff coverage. In interview, the Scheduler stated weekend staffing was the same as weekday staffing, except for a weekend supervisor who was not accounted for during the week, and explained that the facility switched systems used to report PBJ staffing data in January 2026. The Scheduler was unsure who submitted the data but stated that salaried employees working additional shifts were previously reported through Human Resources and that the new system now captures those staff when they clock in. The NHA stated the facility switched payroll systems used for PBJ reporting starting in September 2025 and fully rolled out the system in January 2026, but no additional information was provided to explain why the submitted staffing data was not accurate.
Failure to Maintain Timely 4‑Year Background Check for CNA
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse, neglect, and exploitation policy regarding required 4‑year background checks for employees. The written policy dated 3/2/2026 states that potential employees, contracted staff, students, volunteers, and consultants will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property, and that the facility will maintain documentation proving that such screenings occurred. Record review showed that a CNA hired on 11/2/2020 had an initial Background Information Disclosure (BID) form, Department of Justice (DOJ) letter, and Interagency Border Inspection System (IBIS) form completed on 9/25/2020, prior to employment, but the next documented background check was not completed until 3/10/2026, after the surveyor requested the information. During interviews, the Director of Human Resources acknowledged that when the surveyor requested the CNA’s background check information, it was discovered that no updated background check had been completed within the required four‑year period. The Nursing Home Administrator reported that the facility was purchased by another company in 2022 and stated that all employees had background checks completed in June and July of that year, but at the time of the initial request they were unable to locate the documentation. Later, the Administrator provided a DOJ letter and BID form for the CNA dated 2/10/2022, establishing that a new background check should have been completed by 2/10/2026. The surveyor determined that the background check completed on 3/10/2026 occurred beyond the four‑year timeline and only after it was requested, demonstrating noncompliance with the facility’s abuse prevention screening requirements for one of eight employees reviewed, potentially affecting a portion of the 97 residents in the facility.
Improper Food Storage Temperatures and Labeling
Penalty
Summary
Food was not stored in accordance with professional standards on three unit refrigerators/freezers. On Unit 1, the refrigerator thermometer read 52 degrees F, which was above the facility’s stated acceptable range, even though the temperature log kept at the nurses station documented the refrigerator as consistently 40 degrees F. The RNUM stated temperatures were taken on the night shift and said the thermostat had been turned down after the surveyor pointed out the higher temperature. On Unit 2, the refrigerator thermometer read 34 degrees F, below the facility’s stated acceptable range, and the LPNUM stated the refrigerator was adjusted after the surveyor observed the temperature. On Unit 3, no thermometer was present in the freezer as required by facility policy, and an opened, unsealed bag of mixed fruit was observed in the freezer without a label or date. An LPN present at the time stated there had never been a temperature log for the freezer, and the log only asked for refrigerator temperature. The unlabeled fruit was later discarded after it was observed by survey staff. The NHA was informed of the observations, and the facility later confirmed the concerns were addressed after they were brought to staff attention.
Resident Funds Misappropriation and Exploitation
Penalty
Summary
The facility did not ensure that one resident was free from misappropriation of funds and possible exploitation. The resident had intact cognition with a BIMS score of 13 and was assessed as dependent on two staff for ADLs. The resident was also documented as being their own person and in charge of their own finances. After an anonymous allegation was reported to APS, the facility learned that a CNA had been using the resident’s debit card, receiving cash from the resident, linking the resident’s PayPal account to the CNA’s account, and using the resident’s cell phone. The facility’s own investigation and self-report documented that the CNA admitted getting $400 from the resident, ordering extra food for herself when the resident made food orders, and having the resident’s PayPal account linked to the CNA’s PayPal account. The resident admitted giving the CNA $100, use of a cell phone, and card information. The resident later told the surveyor that the bank card had been given to the CNA so the CNA could already have the information available when the resident wanted to order food, and the resident denied asking for the card back. The resident also stated the facility had provided a locked drawer in the nightstand, but the resident gave the CNA the bank card and it was not taken without the resident knowing. The resident’s trauma assessment documented financial struggle trauma related to not having control of finances and not being aware of the financial situation. The NHA stated the facility called police and initiated an investigation after APS arrived, and that staff interviews did not reveal knowledge of the CNA using the resident’s bank card or taking money. The NHA also stated only about 85% to 90% of staff had been educated on abuse and misappropriation, and the facility had not trained all staff. Surveyor review further noted that after the incident the facility had not assessed or established a plan of care for the resident’s desire to order takeout food and need for staff assistance with ordering, and there was no indication the facility assessed the resident’s need for friendship or loneliness related to the relationship with the CNA.
Failure to Maintain Ordered Palm Guard Use for Resident with Hand Contractures
Penalty
Summary
The facility did not ensure that a resident with limited ROM and bilateral hand contractures received appropriate treatment and services to maintain or improve ROM and prevent further decrease in ROM. The resident had diagnoses including cerebrovascular disease, stroke, gastrostomy tube, and contractures, and the quarterly MDS documented severe cognitive impairment. The resident was dependent on staff for care, mobility, and transfers. The resident had an active MD order for a left hand palm guard to be worn 24 hours a day, with removal allowed for hand hygiene, and a later order for a right palm guard. The resident’s contracture care plan included the right palm guard, but the left palm guard intervention had been resolved from the care plan and was not listed on the CNA Kardex. Surveyors observed the resident multiple times over several days lying in bed with the right palm guard in place but without the left palm guard. The resident’s left hand was described as contracted and, at one observation, partly hanging off the bed. Staff interviews showed confusion about which hand required which device. A CNA stated the resident was supposed to wear a palm guard on the right hand and referenced the CNA Kardex for brace and splint information. An LPN stated both hands had been using palm guards or carrots, then confirmed the resident should be wearing a left palm guard after checking the record, but also noted the left device was not in place during the observation and that a carrot had been placed in the left hand earlier and later found under the bed. Additional interviews confirmed that the left palm guard order had not been discontinued when the right palm guard was added. The OT stated the resident had worn a left palm guard since 2024 and should have both devices in place. The DON stated the left palm guard should have been care planned after being informed that the resident had an active order and that the device was not on the resident during survey observations. The report states the resident’s left palm guard was not part of the active comprehensive care plan or CNA Kardex despite the continuing MD order and repeated observations that it was not in place.
Failure to Notify Ombudsman of Hospital Transfers and Discharges
Penalty
Summary
The facility did not ensure that proper notification was sent to the State Long-Term Care Ombudsman for residents who were transferred or discharged to the hospital. The report identified 6 residents reviewed for transfers or discharges, including R1, R2, R3, R8, R10, and R103, and found that their hospitalizations were not included on the discharge/transfer report provided as evidence that the Ombudsman had been notified. The Nursing Home Administrator and Social Work Director stated that the monthly report was being sent by email, but the report used did not capture all residents transferred or discharged to the hospital. R1 was transferred to the hospital twice for further evaluation after changes in condition, including one transfer on 8/5/25 and another on 10/23/25, and neither hospitalization appeared on the report. R2 was transferred to the hospital on 11/5/25 after a change in condition, and that hospitalization was also missing from the report. R3, who had diagnoses including colon cancer, colostomy, stroke, and type 2 diabetes, was transferred to the hospital on 12/8/25 after a change in condition, but that hospitalization was not listed on the report sent to the Ombudsman. R8, who had diagnoses including Alzheimer’s, dementia, stage 3 chronic kidney disease, and anemia, was transferred to the hospital on 10/13/25 after a change in condition, and this hospitalization was not included on the report. R10, who had heart disease and type 2 diabetes, was transferred to the hospital on 11/21/25 after a clinic visit with a change in condition and again on 2/13/26 for a planned surgical procedure; neither hospitalization was listed. R103 was transferred to the hospital on 1/8/26 for a change in condition and was admitted for acute renal failure, did not return to the facility, and was not included on the discharge/transfer list reviewed by the surveyor.
Inaccurate MDS Coding for Hospice and Smoking Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for three residents, leading to potential missed opportunities for care or services. Resident 23 was marked as not receiving hospice services on their quarterly MDS, despite progress notes indicating they were receiving hospice care until their passing. This discrepancy highlights a failure in accurately reflecting the resident's care status in the MDS. Resident 27 was incorrectly marked as a non-smoker on their annual MDS, although observations confirmed they smoked independently in the designated area. Additionally, Resident 89's admission MDS inaccurately documented them as a non-smoker, despite their smoking assessment and inclusion on the facility's list of smokers. The Minimum Data Set Coordinator acknowledged these coding errors, which were contrary to the guidelines outlined in the Resident Assessment Instrument (RAI) 3.0 manual.
Failure to Develop Smoking Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident identified with smoking behaviors. The facility's policy requires that all safe smoking measures be documented in each resident's care plan. However, a review of the resident's care plan did not reveal any documentation of a smoking care plan, despite the resident's admission smoking assessment indicating that the resident smokes three to four times a day and does not wish to quit smoking. Interviews with the facility's Administrator and Unit Manager confirmed the absence of a smoking care plan for the resident. The Administrator noted that the resident only smokes with family members who maintain his cigarettes, which should have been documented in the care plan. The Unit Manager acknowledged that the smoking care plan was not developed, indicating a lapse in adhering to the facility's policy and comprehensive care planning process.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Greenfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Greendale Park Nursing And Rehab | 0.8 mi | ★★★★★ | 42 | 0 |
| Sunrise Health Services | 1.6 mi | ★★★★★ | 1 | 0 |
| Autumn Lake Healthcare At Greenfield | 1.7 mi | ★★★★★ | 5 | 1 |
| Maple Ridge Health Services | 1.8 mi | ★★★★★ | 0 | 0 |
| Wheaton Franciscan Hc - Terrace At St Francis | 2.6 mi | ★★★★★ | 38 | 0 |
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